Venipuncture has been reported to cause a variety of injuries and there are no sites at which venipuncture can be performed without the risk of nerve lesions. We investigated the sites, symptoms, and treatment of patients who visited our hospital due to venipuncture-induced neuropathy from 2007 to 2012. Sixteen patients (14 women; median age: 40 years) underwent neurological examinations for venipuncture-induced injuries. The puncture sites included the antecubital (68 %), cephalic (19 %), and superficial forearm veins (13 %). Pain occurred in 14 patients. The patients were treated with drug therapy in 13, intravenous lidocaine injections in 8, or nerve blocks in 5. Ten cases almost recovered completely. Medical experts should pay more attention to venipuncture-related nerve injuries, which can occur any site and should be treated immediately.
A 54-year-old male patient who had been receiving medical treatment for a lumbar disc herniation developed lumbar pyogenic spondylitis. Three weeks after antibiotic treatment, the number of leukocytes and the serum level of C reactive protein normalized. However, it was difficult for him to walk and sit because of severe low back pain that had been occurring for more than 3 months after treatment. Generally, interventional treatment on a previously or currently infected area is not recommended; however, taking into account his treatment progress, social context, and desire for treatment, we decided to perform a percutaneous nucleotomy( intervertebral disc biopsy) and radiofrequency-assisted decompressive nucleotomy to evaluate for infection control and treatment of the discogenic pain. After the manipulation, despite not detecting any bacterial agents, his condition had noticeably improved.
Case 1: A 70-year-old woman was referred to our hospital for idiopathic trigeminal neuralgia of the second and third rami. She had been taking medication for 6 months and refused nerve blocks because of dizziness and a feeling of discomfort. She received direct micro-current therapy, which relieved her pain considerably. Case 2: An 80-year-old man with poor oral hygiene and trigeminal neuralgia of the second and third rami complained of severe pain while brushing his teeth. He had received a Gasserian ganglion block twice at a previous clinic. While the pain intensity had decreased, the effects remained insufficient. He received direct micro-current therapy and his pain decreased significantly. Direct micro-current therapy is a non-invasive, suitable treatment for patients with idiopathic trigeminal neuralgia.
A 32-year-old parturient was scheduled for an elective cesarean section with combined spinal and epidural anesthesia. Accidental dural puncture with a 17G epidural needle occurred and she underwent the cesarean section with only spinal anesthesia. The following day, she complained of a severe orthostatic headache, which was strongly suspected to be a postdural puncture headache (PDPH). Plain spinal MRI showed accumulation of epidural fluid, which was considered to be a cerebrospinal leakage. A brain MRI showed bilateral subdural hematoma. She received an epidural blood patch on the 12th postoperative day. The symptoms of PDPH and intracranial hematoma improved gradually. She was discharged three weeks after the operation with no neurological deficits. One month later, a transient headache and intracranial hematoma developed, but a spinal MRI showed no cerebrospinal leakage. Her headache and intracranial hematoma improved without additional treatment within two months. Continuous leakage from the lumbar subarachnoid space can lead to an intracranial subdural hematoma and a spinal MRI may be beneficial for evaluating cerebrospinal fluid leaks.
Electroconvulsive therapy (ECT) may have analgesic effects on neuropathic pain, and the amounts of patient-requested opioids for pain reportedly decrease after ECT. However, no reports have examined the relationship between the analgesic effects of ECT and opioid dosages administered before and after ECT. We reviewed the medical records of 11 patients who underwent ECT while simultaneously using supplemental opioids for pain relief at our institution between March 2003 and March 2012. One case was excluded from analysis due to missing data. Eight of the remaining 10 patients showed decreased usage of opioids during ECT. Furthermore, opioid dosages for 4 of those 8 patients decreased without worsening of neuropathic pain. These results suggest that ECT may alleviate neuropathic pain and allow immediate decreases in opioid dosages for some patients with neuropathic pain.
We report two cases of dorsal root entry zone lesioning (DREZ-lesion) of brachial plexus avulsion injuries involving postoperative opioid dosage reduction. Case 1 involved a 44-year-old man who had taken morphine hydrochloride for more than one year prior to presentation. We planned opioid reduction after DREZ-lesion using an intravenous continuous infusion of fentanyl. However, opioid withdrawal symptoms appeared on postoperative day 1. Case 2 involved a 43-year-old man who had used opioids (most recently fentanyl transdermal one-day patch and tramadol) for pain relief for about 5 years prior to presentation. After DREZ-lesion, opioids were reduced by 20 mg oral morphine equivalents/day and he discontinued opioids without experiencing withdrawal symptoms. The intractable pain caused by brachial plexus avulsion injuries can potentially be relieved by DREZ-lesion. Non-cancer pain patients taking long-term opioids prior to surgery should not cease taking opioids immediately after DREZ-lesion despite postoperative pain relief. Managing perioperative opioid reduction appropriately is essential to limiting the side effects of opioid withdrawal.
A 57-year-old woman with a medical history of hypercalcemia sought care at numerous outside facilities for the treatment of chronic, unexplained, generalized pain prior to presentation at our hospital. No abnormal findings were detected on the examinations, and she was diagnosed with fibromyalgia with depression. She was subsequently administered antidepressants, anxiolytics, and analgesics. She presented to our outpatient clinic with incompletely treated and persistent generalized pain. Accompanying symptoms included mood disturbance, depression, feelings of guilt, delusions, and insomnia; laboratory evaluations revealed elevated serum calcium and parathyroid hormone levels. After subsequent computed tomography and radioisotope testing, she was diagnosed with hyperparathyroidism caused by a parathyroid tumor. Following parathyroidectomy, her pain was alleviated, and the calcium and parathyroid levels normalized. Unexplained and intractable pain may be overlooked as a psychogenic problem. However, we emphasize that in some cases, the etiology of intractable, generalized pain may be related to underlying hypercalcemia.
Herpes zoster (HZ) involving more than two separate dermatomes simultaneously is known as HZ duplex. We present a patient with acute pain from HZ duplex who was treated with an early nerve block. A 61-year-old man presented with diffuse edematous erythema on the left side of his hip (S3 dermatome) and a rash on his right leg (L3 dermatome). One week earlier, he had severe pain in his right leg. Since severe pain persisted despite the administration of acyclovir and analgesics, he was referred to us for treatment of the pain. Both the right leg (L3) with severe pain and the hip (S3) with a severe skin eruption were considered at risk for progression to postherpetic neuralgia (PHN). Continuous epidural analgesia (at spinal level L4/5) was performed and relieved the pain immediately. We conclude that early nerve block may not only have relieved the acute pain in the right leg but also prevented the progression to PHN.
We report two cases of neurologic deficits after spinal anesthesia with 0.5 % hyperbaric bupivacaine. Case 1 involved a 36-year-old woman who underwent cesarean section. She complained of dysesthesia and motor weakness in her left leg, both of which resolved 1 week later. Case 2 involved a 79-year-old man who underwent transurethral resection of the prostate. Postoperatively, he complained of defecation difficulties combined with perianal hypoesthesia. These symptoms have persisted to date, and magnetic resonance imaging revealed severe lumbar spinal canal stenosis. These complications may represent neurotoxicity from local anesthesia.
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